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[Comment] Addressing global health disparities among Indigenous peoples

In countries around the world, Indigenous peoples face great social disadvantages and poor health compared with the general population.1,2 In The Lancet, Ian Anderson and colleagues3 have documented significant disparities among 28 Indigenous populations from 23 countries compared with benchmark populations for several variables, including life expectancy at birth, maternal and infant mortality, and frequency of low birthweight and high birthweight infants. They also showed differences for Indigenous peoples in measures related to nutrition (eg, child malnutrition, childhood obesity, and adult obesity), and in key social indicators, including educational attainment and economic status.

Malnourished das linked to underdeveloped kids

By Caleb Radford, The Lead South Australia
Malnourished fathers could avoid passing on poor health to their children by taking vitamin supplements
and antioxidants before conceiving.
Researchers from the University of Adelaide in South Australia conducted a laboratory study using under-nourished
male mice and found a direct correlation between the health of the offspring and the father’s health at the time of
conception.
University of Adelaide researcher Nicole McPherson said previous studies had looked at the affect of malnutrition in
mothers but new evidence suggests that paternal influences could play a more direct role.
“Malnutrition is a serious issue and affects hundreds of millions of people around the world,” she said.
“The biggest issue is that people dismiss men’s health and it’s impact on the health of their children, whether that is
under-nutrition or over-nutrition.
“However, we now know that the parents’ health at the moment of conception is incredibly important. What we’re
seeing from our research is that some form of dietary supplementation may also benefit fathers-to-be.”
There are about 2 billion people in the world who suffer from various forms of malnutrition. About 2.6 million children
die from malnutrition each year, which accounts for a third of child deaths globally.
Under-nutrition is considered to be the number one risk to health worldwide and accounts for 11 per cent of the
global burden of disease.
The research study found that the offspring of malnourished male mice were born underdeveloped and showed
evidence of abnormal gene expression and metabolic markers.
These offspring were prone to health conditions including increased risk of non-communicable diseases,
cardiovascular disease and type 2 diabetes, mirroring the situation for human children born in the developing world.
Researchers responded by altering the diet of the male mice to include additional zinc, folate, iron and other vitamin
supplements.
This resulted in improved fertility rates, healthier children and normal metabolic markers.
“A father’s health at the time of conception is really important – their particular dietary quality and nutrient
sufficiency,” Dr McPherson said.
“We hope that these findings could eventually be translated into interventions, to help reduce the health burden of
under-nutrition to the world.”
“This is however a laboratory study and we still need to do more research.”
The study titled Paternal under-nutrition programs metabolic syndrome in offspring which can be reversed by
antioxidant/vitamin food fortification in fathers has been published in the Nature journal Scientific Reports.

Life expectancy up, but Africa still behind – WHO

A new report has highlighted the disturbing extent of health inequality across the globe, showing that while life expectancy has risen at its fastest rate since the 1960s, sub-Saharan Africa still lags the rest of the world by a considerable margin.

The World Health Organisation (WHO) figures show that global life expectancy increased by five years between 2000 and 2015 – the fastest increase since the 1960s.

The African region had the strongest growth, up by 9.4 years, driven by improvements in child survival, malaria control and access to retrovirals for HIV treatment.

The increase has narrowed the gap between African life expectancy and European life expectancy by 4.9 years since 2000.

But even so, a child born in Africa in 2015 can only expect to live to the age of 60, compared with the global average of 71.4 years.

A child born in Sierra Leone has a life expectancy of just 50.1 years, more than 33 years less than a child born in Switzerland (83.4). An Australian (82.8 years) can look forward to three more decades than an Angolan (52.4 years).

“The world has made great strides in reducing the needless suffering and premature deaths that arise from preventable and treatable disease,” WHO Director-General Dr Margaret Chan said.

“But the gains have been uneven. Supporting countries to move towards universal health coverage based on strong primary care is the best thing we can do to make sure no-one is left behind.”

The World Health Statistics: Monitoring Health for the SDGs report shows that the declines in life expectancy experienced in the 1990s, caused by the AIDS epidemic in Africa and the impact of the collapse of the Soviet Union on eastern Europe, have been reversed.

“The global average increase in life expectancy at birth since 2000 exceeds the overall average rate of life expectancy increase achieved by the best performing countries over the past century,” WHO said.

“The world as a whole is catching up with those countries, and improvements in outcomes for all major causes of death have contributed to these huge gains.”

WHO said it was worth considering a proposal to measure premature mortality – deaths before the age of 70 – as it was more sensitive to interventions.

“There were an estimated 30 million deaths under age 70 in 2015 and, if the Sustainable Development Goals (SDG) mortality targets had been achieved in 2015, this would have been reduced to 19 million deaths,” the report said.

“This represents a 36 per cent reduction (almost 11 million averted premature deaths) – close to the proposed 40 per cent target.”

Had those deaths been averted, five million people would not have died from infectious diseases, malnutrition, and child and maternal mortality. A further five million would not have lost their lives to non-communicable diseases, and 900,000 people would not have died from injuries.

The report found that Japan topped the life expectancy list, at 83.7 years, and Sierra Leone was the lowest (50.1).

Healthy life expectancy, a measure of the number of years of good health a 2015 newborn can expect, stands at 63.1 years globally – 64.6 years for women and 61.5 for men.

On average, women (73.8 years) live longer than men (69.1 years) in every country of the world. Scandinavian countries had the lowest male-female gaps (Iceland 3.0 years, Sweden 3.4) while some former Soviet countries were among the highest (Russia 11.6 years, Ukraine 9.8 years).

The full report can be found on the WHO website at http://www.who.int/gho/publications/world_health_statistics/2016/en/

Maria Hawthorne

 

Seeing Europe the hard way

By Adrian Rollins, Editor, Australian Medicine

In the past, when winter hit hard in Australia, those who could afford it would fly to Europe to bask in the Mediterranean sunshine, visit a museum or two, eat great food, imbibe stunning wines and generally lap up the warmth.

But the days there are many travellers making their way to Europe for whom rest and relaxation is the last thing on their mind.

With a bicycle in their luggage, and months of hard training in their legs, they are making pilgrimages to the fabled climbs of the Alps, the Pyrenees, and the Dolomites.

This time last year, I was among their number.

It was with more than a little trepidation that, to mark my impending fiftieth year on the planet, I signed up for the Haute Route Triple Crown, a cyclosportive that would involve cycling 2700kms through the Pyrenees, the Alps and the Dolomites in just 23 days – climbing more than 60,000 metres in the process.

With some reason, the organisers of the Haute Route bill it as the highest and toughest cyclosportive in the world.

Taking the anxiety level up a few notches, there was a daily cut-off time – miss the cut, and you were out of the running to be an officially recognised finisher. Translated, that meant: no bad days.

For a rank amateur such as myself, it was the closest I would ever get to experiencing the life of a pro cyclist.

For three weeks, the only thing I had to concentrate on each day was hauling myself and my bike over some of Europe’s biggest mountains, and make sure I was in good enough shape to do it all again the following day.

In many ways, it felt like the cycling equivalent of the rock star lifestyle, except with completely shattered legs, an inability to stay awake after about 9pm, no sex and no enjoyable drugs (ibuprofen doesn’t count).

The original plan had been to just ride the Pyrenees. But my wife argued, with compelling logic, that if I was going to fly around to the other side of the world to ride my bike, I should do the whole thing. I didn’t do the sums, but on a dollar per kilometre count, it seemed to make sense.

All I had to do was convince my legs (and my bum, back, neck, arms and even hands) that it was a good idea as well.

After 12 months of intense training (and endless fussing about gear and nutrition), I made it to the start line in Anglet, a small French port on the Atlantic coast just up the road from Biarritz on 15 August to begin the biggest cycling – nay, sporting – adventure of my life.

The Haute Route is organised like a full Grand Tour (not surprising, since it is planned and run by many of the same people responsible for Tour de France). Every morning there is a grand depart from the middle of town, there are motorcycle escorts and outriders, there are time limits, feeding zones, Mavic support vans and a legion of volunteers who patrol every village and intersection the ride goes through.

Zipping through little mountainside hamlets lined with clapping locals, hurtling across village squares and through cross roads, all without barely having to touch the brakes, was exhilarating.

So too were the views. To actually ride up cols I had only ever seen in late-night broadcasts of the Le Tour and the Giro was unforgettable – particularly so because I probably took about three times as long as the slowest pro.

The Haute Route took us up and over many of the iconic climbs – the Tourmalet; Hautacam; Izoard; the highest mountain pass in the Alps, Col de la Bonnette; the Col de la Croix de Fer; the Furka Pass in the Swiss Alps; the Gavia and the Giau in the Dolomites.

All up, the 28 of us who embarked on the Triple Crown would climb 57 cols before reaching our destination in Venice on September 6.

Competing in the Haute Route for the whole three weeks is to be in a bike-infused bubble.

Mentally, there is little down time.

Virtually every waking moment is spent either working on recovering from the ride you’ve just finished, or preparing for the ride to come.

As my fellow Triple Crowner Howard Galloway put it, we were velo: we had morphed into cycling machines operating at a base level of consciousness whose overriding purpose was to turn pedals.

There is no getting away from the fact that this is an enormous mental challenge.

Often people say they “find themselves” on such adventures. I can’t say that happened for me. What I did find was that (a) Europe has a LOT of cows; (b) you have to be careful where you step in the bushes behind rest stops; and (c) you can get out of bed and onto a bike while still half asleep.

If you want to hone your capacity for doggedness and persistence, the HR Triple Crown is the perfect place to do it.

As the three weeks unfolded and the kilometres mounted, the novelty of being a bike “pro” gradually morphed into a familiar rhythm – get to the end of the stage, quickly quaff some recovery drink, scoot to the hotel, book a massage, have a quick shower, get your gear ready for the next day, go to dinner and then crash.

But constant challenges and changes meant no two days were ever alike.

On some there was barely a flat spot, while on others two summits would be separated by a long valley haul where joining a bunch was essential to save much-needed energy. Occasionally, the route went along a major road, at other times along riverside bike paths.

Just about every night meant a new town and hotel. Some days finished with a transfer – including, memorably, finishing the Pyrenees ride on the outskirts of Toulouse and dashing to the nearby airport to catch a flight to Nice in time to start the Alps leg.

Then there were the constantly shifting weather patterns that meant we experienced everything from baking heat to torrential rain, fog, snow and ice (sometimes in the same day).

On top of this, each week the character of the ride changed as a new influx of cyclists descended on the event.

The Haute Route is actually comprised of three discrete week-long events, and this is what most sign up for.

For those of us doing the Triple Crown, it was almost like doing a stage race in which 90 per cent of the peleton was replenished with fresh riders at the start of every week. It meant that there was a constant cavalcade of new people to meet and be entertained by.

Aside from the spectacular scenery, tortuous climbs and demanding descents, the fact is that when you draw together 600 keen cyclists from around the world, you are bound to see some pretty unusual and amusing sights.

Like the jostling among riders huddling in the narrow doorway of what looked like an electricity substation at the summit of the Izoard in a vain attempt to shelter from a massive storm lashing down.

Or the spray of excrement that showered a bunch as it hit a 200-metre patch of road on the descent of the Tourmalet that was smeared in a layer of cow manure.

Then there was the local spotted high up on the flanks of the Tourmalet riding a recumbent which had a door-sized solar panel strapped to the top – which would have made the next 20 kilometres of descending interesting.

Alongside the weird and wonderful sights, there were the inevitable crashes as people explored – and occasionally exceeded – the limits of their ability.

Nestled in the heart of the Alps, the Col de Madeleine is a challenging climb. But the struggle up is worth it for the glorious descent. Perfectly engineered switchbacks cut a sinuous path through the heavily forested flanks of the mountain before entering a deep and lush valley with sheer rock walls rearing up one side, and a sharp drop to a river on the other.

It feels made for fast descending.

Unfortunately, it brought several badly unstuck. As I came around one bend I flashed past a figure in blue and black lycra crouched by the side of the road clutching his right shoulder in the classic “I think I’ve broken my collarbone” posture, with the motorbike medic just pulling up to render assistance.

A couple more kilometres down the descent, people were swarming by the side of the road where an ambulance had stopped. A cyclist had lost it on a sweeping bend and gone over the side. He had landed in the upper braches of a large pine tree and broken his femur. The rescue crews had to winch him down.

Staying upright and healthy for the whole three weeks is a big part of the challenge, and just about all those who attempted the Triple Crown were at some stage forced to battle illness or injury.

Incredibly, just about all those who embarked on the journey in Anglet made it through to Vienna.

The Haute Route is not a race, but daily time limits mean it is not a cruise either.

There are undoubtedly tougher one-day rides on the calendar, but it is hard to dispute its claim to being the highest and toughest cyclosportive in the world.

The Haute Route – my top 10 tips

  1. Sign up with an official tour operator (I used Sydney-based Will Levy and his Two Wheel Tours team, who were fantastic). You can book accommodation through the Haute Route organisers, but unless you don’t mind wondering around a French ski resort for a couple of hours after finishing a nine-hour ride trying to find your hotel, only to discover the single room you booked is now also shared with two other sweaty cycling strangers, a tour company that looks after everything except the cycling is the way to go.
  2. Pace yourself. Each week begins with a frenzy at the front, as adrenaline-filled riders battle for a place near the head of the peleton. Unsurprisingly, the first day is when some nasty accidents happen. Hold a little back in the first few days, and you will make up plenty of places by then end of the week.
  3. Carry a rain jacket. Even if there is no rain, you can quickly get very cold on the long descents. A jacket and a bit of newspaper under the jersey can be lifesavers.
  4. Don’t dawdle at rest stops. It is easy to waste a lot of time at the feed stations. Top up your bottles, grab some food and keep going. You want to stay ahead of the Lantern Rouge.
  5. Avoid the first rest stop of the day (where possible). The first feed station is invariably a bun fight. Carry enough food and water to get you through to the second feed station.
  6. Ride smart. Do your turn in the bunch, but don’t try to ride the peleton off your wheel. You will pay for it. Similarly, it’s worth working hard to stay in a bunch in the long flat sections (which can sometimes be 60 kilometres long), but if you are at risk of blowing, ease off.
  7. Use the bunches. Often the descents are not timed, and at the bottom cyclists will gather just before the timing mat. Pull over and wait with them until a bunch forms up. It’ll save you valuable energy, and will usually get you to the end just as quickly.
  8. Start at the front. In a contradiction to #2, it is smart to start towards the front on every day except the first day of the week. The top 75 riders are sent off ahead of the pack, and then it is everyone for themselves. If you start toward the front, you can settle into one of the big bunches and get a drag to the first climb of the day, then ride at your own pace.
  9. Get prepared. Every night, do as much as you can to get yourself ready for the next day. The rides usually begin at 7am, which means getting up around 5.30 or so. The less you have to do (and remember) at that time of the morning, the better. Get your gear out, put on your bib number, set out the food you’ll carry. Have your water bottles handy, and have your bags pretty much packed.
  10. Pack your own lunch. Haute Route provides a lunch, but unless you are confident you’ll be in the first hundred or so, you’ll find that a lot of the nicest food is gone and you are left with a choice between boiled fish, gluggy pasta and dried out rice. At breakfast, make yourself a roll or two and stash them in your bag ready to scoff at the end.

 

Breaking bread delivers big health rewards

There has been a significant decline in serious birth defects following the mandatory fortification of bread with folic acid and iodine.

Signalling a major public health success, the Australian Institute of Health and Welfare has found that the rate of neural tube defects has plunged by almost 75 per cent in babies born to Indigenous mothers, and are down by 55 per cent among babies born to teenage mothers, following the mandatory fortification of bread with folic acid and iodine.

Since 2009, millers have been required to add folic acid and iodine to flour following evidence that deficiencies in the diet of mothers was helping prevent neural tubes in foetuses from closing, causing serious birth defects such as spina bifida.

Research has shown that folic acid taken at recommended levels for at least one month before and three months after conception can prevent most neural tube defects.

The AIHW reported that since mandatory folic acid fortification was introduced, the overall incidence of neural tube defects has declined by 14.4 per cent, including major declines among teenagers and the Indigenous community.

It also found that the addition of iodine to bread had addressed the emergence of mild iodine deficiency in the general population.

AIHW spokesperson said these were “promising” results, but said further data collection was required to ensure these findings were accurate and sustained.

The full report is at: http://www.aihw.gov.au/food-and-nutrition/folic-acid-and-iodine/

Adrian Rollins

[Correspondence] The double burden of malnutrition associated with poverty

Undernutrition remains a serious health issue for women and children in several developing countries, as pointed out by George Davey Smith in his Comment on the report on BMI trends (April 2, p 1349).1 However the situation is not exclusively undernutrition for the poor and overnutrition for the better off. The burden of obesity shifts progressively from the wealthier to the poorer groups with rising country income.2

Changing eating patterns versus adding nutrients to processed foods

Food-based dietary guidelines are necessary but the processed food industry prefers to concentrate on individual nutrients

Excess weight affects 70% of men, 56% of women and 25% of children in Australia,1 increasing the risk of type 2 diabetes, cardiovascular disease, some common cancers and musculoskeletal problems.

Genetic factors have an influence in obesity, but sedentary lifestyle and our eating patterns also contribute to the national girth. We move less and eat more, especially discretionary (junk) foods which now constitute 35% of adults’ and over 40% of children’s kilojoule intake.2 Plates, bowls, glasses and cups are bigger and contribute to greater consumption.3,4 Supermarkets and food outlets have extended hours. Eating home-cooked meals at the family table is often replaced with snacks and convenience foods, and children’s lunchboxes usually contain junk food “treats”.

There is no evidence that adding nutrients to poor food choices will fix this situation. In keeping with the World Health Organization recommendations since 1995,5 Australia’s 2013 dietary guidelines were based on evidence about whole foods rather than individual nutrients.2 This approach is not popular with the food industry, which opposes suggestions that we should eat less of any food,6 and prefers to improve diet quality by adding nutrients. This results in an increasing range of highly processed foods with added vitamins, minerals, protein concentrates, omega-3 fatty acids, prebiotics and probiotics, and various phytonutrients. Such foods cannot make up for the fact that just 5.5% of Australians have an adequate usual intake of vegetables and fruit,7 and most consume less than half the recommended quantity of wholegrains.2

The food industry does not necessarily object to the “eat less” advice applied to nutrients. Messages to consume less fat led to profitable low-fat foods. These have little value for weight control when the fat is replaced with sugar and refined starches. There is an industry backlash about reducing sugar (always one of Australia’s dietary guidelines), but innovative companies are producing high-fat, low-sugar products. However, there is no evidence that they help with weight control.

A nutrient-centred approach also suits supplement makers. Whole supermarket aisles are now piled with pills and powders containing nutrients and herbal concoctions in various combinations for different ages and stages of life. These products are also providing a profitable export market and many are also sold by gyms, fitness centres and pharmacies, often with endorsement from celebrity and sports stars. Again, there is no evidence that they assist with weight control.

Nutrient-enriched foods will not solve Australia’s weight problem. Adding vitamins and minerals to sugary cereals or chocolate-flavoured powders to stir into milk or sprinkle over ice cream is worse than useless. The subtle message accompanying such products is that it is safe to eat more. Messages to eat less go against the grain with those whose profits depend on us consuming more. Nutrient supplements are also problematic when advertised or used to balance a poor diet.

Food-based guidelines recommend whole foods and provide advice about which foods to restrict. They also provide guidance on cooking and eating patterns, and sustainable use of resources, including agricultural factors involved in production of livestock and crops for food and animal fodder. Highly processed foods do not fit well with food-based dietary guidelines. However, such foods, and the demise of more traditional cultural eating patterns, have accompanied the increasing incidence and prevalence of obesity.6

Worldwide, nutritionists are recommending changes in eating patterns rather than nutrient-enriched processed foods. In the United States, an advisory report on the 2015 dietary guidelines recommended a dietary pattern rich in vegetables, fruit, whole grains, seafood, legumes and nuts; moderate in low- and non-fat dairy products and alcohol (among adults); lower in red and processed meat; and low in sugar-sweetened foods and beverages and refined grains.8 It also reported that a diet higher in plant foods and lower in calories and animal foods was associated with less environmental impact than the current US diet. Critics reacted. The US Congress passed a bill ensuring that sustainability issues were dropped. In 2016, the final guidelines did give more emphasis to eating patterns and reiterated the WHO call to limit sugar,9,10 but recommendations encouraging a more plant-based diet, opposed by meat producers, were ignored. The advisory committee’s call to limit exposure and marketing of foods and beverages high in added sugars and sodium was also dropped.8

The Nordic countries also emphasise the need to change eating patterns,11 and Brazil’s guidelines set a new bar.12 The Brazilian advice is to base the diet on natural or minimally processed foods; limit intake of processed foods and avoid those that are ultra-processed; eat regularly and carefully in appropriate environments (in company where possible); avoid fast food chains; and be wary of advertising and marketing.12 Following such direct guidelines could reduce consumption of junk food and help solve our obesity crisis. Trying to fix poor food choices by adding extra nutrients avoids the real problem.

[Comment] Acting in the Anthropocene: the EAT–Lancet Commission

Expanding waistlines are a problem not just for dietitians and population health specialists but, increasingly, for Earth system scientists too. The waistlines belong largely to the growing global middle class. The world is undergoing a dramatic nutrition transition to western diets. Wealth, industrialisation, and rapid urbanisation are driving a surge in resource-intensive meat and dairy products and ultra-processed foods. This dietary shift is the main cause of an exponential rise in obesity and non-communicable diseases (NCDs).

[Correspondence] Breastfeeding in the 21st century

Although the beneficial effects of longer breastfeeding duration are better understood,1 virtually nothing is known about the long-term impact in vulnerable populations such as small for gestational age (SGA) newborn babies. Low-birthweight persistently affects the individual’s health or disease patterns, increasing the risk for chronic non-communicable diseases.2 This factor is preceded by nutritional imbalances due to specific feeding preferences shown by SGA individuals over their life course.

[Correspondence] Breastfeeding in the 21st century

The Lancet’s Series on breastfeeding1,2 has shown the nutritional, immunological, and developmental inferiority of breastmilk substitutes, and the contribution of breastfeeding to the survival and health of children and their mothers in all countries. It does not, however, address the needs of the infants most vulnerable to nutritional, immune system, growth, and developmental compromise; those born preterm, growth retarded, or who are sick. These infants and their mothers need special protection and support to enable breastfeeding and feeding with breastmilk, yet paradoxically they are often denied rights normally accepted unconditionally for full term infants.